Monday, June 2, 2014

You Gets What You Pays For: Forensics Edition

Recently in the news,  North Carolina Medical Examiners were criticized for violating State law for not examining bodies or doing forensic death investigations in sudden or suspicious deaths that fell under their jurisdiction. In a five part series published by the Charlotte Observer, which contains heartbreaking testimonials by family members who were harmed by inadequate or incomplete death rulings, the Chief Medical Examiner for the State, Deborah Radisch MD, pointed out that North Carolina pays 84 cents per capita for its death investigation system, compared to the nationwide average of $1.76. "You get what you pay for" said Dr. Vincent DiMaio, the retired Chief Medical Examiner of Bexar County, TX, where the death investigation system costs a respectable $2.30 per capita.

Meanwhile, in Maine, the backlog has gotten so bad that they won't even take the time to measure it, the Chief is retiring and they are worried they won't find forensic pathologists to do the work. Why? Underfunding again. Yet while some economists recognize that autopsies are a public good and should be funded by the government, like lighthouses, getting adequate funding is difficult. Since death investigation is run on the county level the investment rests on county supervisors and executives, who are more interested in spending on services for living voters. This is source of the "medical examiner cycle," described by Dr. Shapiro in the Maine Press Herald article: offices get neglected until there is an embarrassing screwup; then heads roll and Chief is let go or demoted. Money gets freed up to recruit new staff, get accreditation, but as soon as the office becomes successful, fully staffed, well-run, and out of the news, the cutbacks begin and the cycle starts again.

What about Federal funding? Well a current Federal government report on forensic pathology points out that "under current Federal policies, ME/C are effectively ineligible for direct Federal funding and cannot receive grants from the Department of Health and Human Services (including the National Institutes of Health [NIH]), the Department of Justice, or the Department of Homeland Security." Coverdell grants, which offices are eligible for, are mentioned in this report but they cover equipment, accreditation and certification; they don't cover staffing or autopsies. The more understaffed an office is, the less likely it will have a person on staff who can dedicate the time required for grant application, paperwork and expenditures. So once an office is at the low point in the "medical examiner cycle" it is unlikely to be able to get out using Coverdell grants alone - just wait until the inevitable political embarrassment that will get the office some funding.

What can we do to prevent this and bring stability to the field? We need a Federal effort to help local counties fund and support their death investigation facilities with matching funds. Eligibility must be contingent on a minimum per capita investment by the local agency, with adjustments based on inflation. The matching funds for accreditation are the carrot but there needs to be a stick as well. One suggestion would be ineligibility for federal law enforcement funding support if the office is part of a Coroner and/or ineligibility for public health research funding if it is a public health agency. What I have seen in over 10 years as a public servant is that unfunded mandates do not work. It is not enough to require accreditation and training. There needs to be funding to support it. When there are reliable, well-paying jobs in the forensic sciences, students will enter the field and there will no longer be a lack of forensic pathologists. There is plenty of interest in forensics, but little motivation among physicians to take a high-profile public sector job for less money than they can make with fewer years of training. If you fund it, however, they will come.